Blood Samples
US HAEA Scientific Registry
Research for a Cure

Signing up as volunteer is easy. Your participation is key to future medical research that will change lives – yours, those of your loved ones and everyone whose lives are affected by HAE.

Once the Registry Administrator verifies that you qualify, you will receive a confirmation letter along with a Consent Form to read, sign, and return.  The information you provide will be kept strictly confidential.


First Name: 
Last Name: 
Maiden Name: 
(if applicable)
 
Gender:  Male Female
 
Address: 
 
 
City: 
State:    Zip Code: 
 
Home Phone Number: 
Cell Phone Number: 
E-mail address: 
Secondary E-mail address: 
 
Date of Birth: 
 
Diagnosis: 
 
Ethnicity: 







 
Are you a member of the US HAE Association?  Yes No
Do you have a blood relative with known HAE?  Yes No
Do you have a blood relative with HAE who is currently participating in this research project?  Yes No



Sign up to be a volunteer in our patient driven research for a cure.

The greater the numbers of members, the greater our chances of success.

Have questions?
Contact Registry Administrator
Anna Chenoweth

(866) 798 - 5598

US HAEA Scientific Registry
PO Box 471532
Chicago, IL 60647


Scientific Registry